Basic Information
| Provider Information | |||||||||
| NPI: | 1205951084 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LEWIS COUNTY PRIMARY CARE CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PRIMARYPLUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 550 | ||||||||
| Address2: | |||||||||
| City: | VANCEBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411790550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067963029 | ||||||||
| FaxNumber: | 6067966221 | ||||||||
| Practice Location | |||||||||
| Address1: | 17521 W KY 9 | ||||||||
| Address2: | |||||||||
| City: | TOLLESBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067983151 | ||||||||
| FaxNumber: | 6067982222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 01/28/2015 | ||||||||
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| AuthorizedOfficialLastName: | UGRIN | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6067963029 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 700041 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 31000268 | 05 | KY | MEDICAID |